CANDLE Leadership Project Application

General Information

IMPORTANT: You must be between the ages of 18-24 and not currently attending TRUST or the Trans Youth Group to begin volunteering with the Leadership Project.

DISCLAIMER: This information will be kept strictly confidential. It will only be used by CANDLE staff, and no identifying information will be shared outside of the Youth Pride Initiative at CANDLE, unless the client is in danger or others are threatened or harmed by the client.

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1.Today's Date:

Ex: 07/10/2014

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2.Name:

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3.Date of Birth:

Ex: 07/10/2014

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4.Ethnic/Racial Identity:(Check all that apply.)

White

Black/African-American

Latinx

Asian

Native Hawaiian/Pacific Islander

Native American

Click this to tell us below ->

Feel free to tell us how you identify here or to elaborate on your identify (especially if not represented above):

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5.Gender:(Check all that apply.)

Cisgender Woman

Cisgender Man

Transgender Man

Transgender Woman

Genderqueer/fluid

Gender nonconforming

Agender

Demigender

Trans

Click this to tell us below ->

Feel free to tell us how you identify here or to elaborate on your identify (especially if not represented above):

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6.The pronouns you use are:(he/him/hisshe/her/hersthey/them/theirsZe/hir/hirsZe/zir/zirsetc.)

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7.Sexual Orientation:(Check all that apply.)

Lesbian / Gay (attraction to those of same gender)

Straight (attraction to those of "opposite" gender)

Bisexual (attraction to those who are within gender binary)

Skoliosexual (attraction to those who are outside of the gender binary)

Pansexual (attraction to all those along the spectrum)

Asexual (experience little to no sexual attraction)

Demisexual (does not experience sexual attraction unless they form a strong emotional connection with someone)

Queer (attraction to various people and identities)

Click this to tell us below ->

Feel free to tell us how you identify here or to elaborate on your identify (especially if not represented above):

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8.Home Address:

Street Address:

Apt.

City/Town:

State:

ZIP:

Email:

Cell/Home Phone:

Facebook:

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9.Which is the best way to contact you about events and volunteer opportunities?

Call

Text

Email

Facebook

Other (please specify)

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10.Which of these are shared with other people?

Phone

E-mail

Facebook

None of the above

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11.How did you find out about this group?

Friend:

Saw a flyer (location):

Newspaper/Magazine/Directory (which one):

Referred by adult:

Organization:

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12.In case of emergency, what responsible person would you like us to contact?(No one will be contacted unless you are a danger to yourself or others.)

Name:

Relation to You:

Address:

Apt.:

City/Town:

State:

ZIP:

Phone:

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13.Does this person know that you go to a group at CANDLE? What should we say if we need to call?